Intensive care medicine

Professor
Vladimir Pichugin
Definition
 Intensive Care Medicine or
critical care medicine is a
branch of medicine concerned with
the provision of life support or
organ support systems in patients
who are critically ill and who
usually require intensive
monitoring.
 Patients requiring intensive care usually
require support for
 hemodynamic instability (hypertension/
hypotension),
 airway or respiratory compromise (such
as ventilator support),
 acute renal failure,
 potentially lethal cardiac arrhythmias,
 and frequently the cumulative effects of
multiple organ system failure.
 Patients admitted to the intensive care
unit not requiring support for the above
are usually admitted for
intensive/invasive monitoring, such as
the crucial hours after major surgery
when deemed too unstable to transfer
to a less intensively monitored unit.
 Ideally, intensive care is usually only
offered to those whose condition is
potentially reversible and who have a
good chance of surviving with intensive
care support.
 Since the critically ill are so close to
dying, the outcome of this intervention
is difficult to predict.
 Many patients, therefore, die in the
Intensive Care Unit. A prime requisite
for admission to an Intensive Care Unit
is that the underlying condition can
be overcome.
 It is generally the most
expensive, technologically
advanced and resource
intensive area of medical care.
 In the United States estimates of
the 2000 expenditure for critical
care medicine ranged from US$15-
55 billion accounting for about
0.5% of GDP and about 13% of
national health care expenditure.
 Organ systems
 Intensive care usually takes a system by
system approach to treatment, rather than
the SOAP (subjective, objective, analysis,
plan) approach of high dependency care.
 The nine key systems (see below) are each
considered on an observation-
intervention-impression basis to
produce a daily plan.
 As well as the key systems, intensive care
treatment also raises other issues including
psychological health, pressure points,
mobilization and physiotherapy, and
secondary infections.
 Organ systems
 The nine key IC systems are (alphabetically):
cardiovascular system, central nervous system,
endocrine system, gastro-intestinal tract (and
nutritional condition), hematology, microbiology
(including sepsis status), peripheries (and skin),
renal (and metabolic), respiratory system.
 The provision of intensive care is generally
administered in a specialized unit of a hospital
called the Intensive Care Unit (ICU) or Critical
Care Unit (CCU).
Equipment and systems
 Common equipment in an intensive care
unit (ICU) includes: mechanical ventilation
to assist breathing through an
endotracheal tube or a tracheotomy;
hemofiltration equipment for
acute renal failure; monitoring equipment;
intravenous lines for drug infusions fluids
or total parenteral nutrition,
nasogastric tubes, suction pumps, drains
and catheters; and a wide array of drugs
including inotropes, sedatives, broad
spectrum antibiotics and analgesics.
 Intensive care unit
 An intensive care unit (ICU), critical care
unit (CCU), intensive therapy unit or
intensive treatment unit (ITU) is a
specialized department used in many
countries' hospitals that provides intensive
care medicine.
 Many hospitals also have designated
intensive care areas for certain specialities of
medicine, as dictated by the needs and
available resources of each hospital. The
naming is not rigidly standardized.
 Types. Specialized types
of ICUs include:
 Neonatal intensive care unit (NICU)
 Special Care Nursery (SCN)
 Pediatric intensive care unit (PICU)
 Psychiatric Intensive Care Unit (PICU)
 Coronary Care Unit (CCU) for heart disease
 Cardiac Surgery Intensive Care Unit (CSICU)
 CardioVascular Intensive Care Unit (CVICU)
 Mobile Intensive Care Unit (MICU)
 Medical Surgical Intensive Care Unit (MSICU)
 Medical-Surgical Critical Care Intensive Care Unit (MSCC)
 Surgical Intensive Care Unit (SICU)
 Overnight Intensive Recovery (OIR)
 Neuroscience Critical Care Unit (NCCU)
 Neurological Intensive Care Unit (NICU)
 Neuro Intensive Care Unit (NICU)
 Burn Wounds Intensive Care Unit (BWICU)
 Trauma Intensive care Unit (TICU)
 Shock Trauma Intensive care Unit (STICU)
 Trauma-Neuro Critical Care Intensive Care Unit (TNCC)
 Respiratory Intensive Care Unit (RICU)
 Geriatric Intensive care unit (GICU)
 The criteria for
admission to an ICU
 Critically ill patients in a medically unstable state
who require an intensive level of care (monitoring
and treatment).
 Patients requiring intensive monitoring who
may also require emergency interventions.
 Patients who are medically unstable or critically
ill and who do not have much chance for recovery
due to the severity of their illness or traumatic injury.
 Patients who are generally not eligible for ICU
admission because they are not expected to
survive. Patients in this fourth category require the
approval of the director of the ICU program
before admission.
 ICU care requires a multidisciplinary
team that consists of but is not limited
to intensivists (clinicians who specialize
in critical illness care); pharmacists and
nurses; respiratory care therapists; and
other medical consultants from a broad
range of specialties including surgery,
pediatrics, and anesthesiology.
 The ideal ICU will have a team
representing as many as 31 different
health care professionals and
practitioners who assist in patient
evaluation and treatment.
 The intensivist will provide treatment
management, diagnosis, interventions,
and individualized care for each patient
recovering from severe illness.
 Description
 ICUs are highly regulated departments, typically
limiting the number of visitors to the patient's
immediate family even during visiting hours.
 The patient usually has several monitors for real-
time evaluation of medical stability.
 The intensivist will make periodic assessments
of the patient's cardiac status, breathing rate, urinary
output, and blood levels for nutritional and hormonal
problems that may arise and require urgent attention
or treatment.
 Patients who are admitted to the ICU for
observation after surgery may have special
requirements for monitoring. These patients may
have catheters placed to detect hemodynamic
changes, or require endotracheal intubation, with the
breathing tube connected to a mechanical ventilator.
Description
 In addition to the intensivist's role
in direct patient care, he or she is
usually the lead physician when
multiple consultants are involved
in an intensive care program.
 The intensivist coordinates the
care provided by the
consultants, which allows for an
integrated treatment approach to
the patient.
 Description
 Nursing care has an important role in an intensive care unit.
The nurse's role usually includes clinical assessment, diagnosis,
and an individualized plan of expected treatment outcomes for
each patient (implementation of treatment and patient
evaluation of results).
 The ICU pharmacist evaluates all drug therapy, including
dosage, route of administration, and monitoring for signs of
allergic reactions. In addition the ICU pharmacist is also
responsible for enteral and parenteral nutrition (tube
feeding) for patients who cannot eat on their own.
 ICUs also have respiratory care therapists with specialized
training in cardiorespiratory care for critically ill patients.
 Respiratory therapists generally provide medications to help
patients breathe as well as the care and support of mechanical
ventilators and also evaluate all respiratory therapy procedures
to maximize efficiency and cost-effectiveness.
Description
 In general there are eight categories
of diseases and disorders that are
regarded as medical justification for
admission to an ICU.
 These categories include disorders of
the cardiac, nervous, pulmonary, and
endocrine (hormonal) systems, together
with postsurgical crises and medication
monitoring for drug ingestion or
overdose.
 Description
 Cardiac problems can include heart attacks
(myocardial infarction), shock, cardiac arrhythmias
(abnormal heart rhythm), heart failure (congestive
heart failure or CHF), high blood pressure, and unstable
angina (chest pain).
 Lung disorders can include acute respiratory failure,
pulmonary emboli (blood clots in the lungs), hemoptysis
(coughing up blood), and respiratory failure.
 Neurological disorders may include acute stroke
(blood clot in the brain), coma, bleeding in the brain
(intracranial hemorrhage), such infections as
meningitis, and traumatic brain injury (TBI). Medication
monitoring is essential, including careful attention to
the possibility of seizures and other drug side effects.
 Intensive care unit
equipment
 Intensive care unit (ICU) equipment includes
 patient monitoring,
 respiratory and cardiac support,
 pain management,
 emergency resuscitation devices,
 and other life support equipment designed to
care for patients who are seriously injured, have
a critical or life-threatening illness, or have
undergone a major surgical procedure, thereby
requiring 24-hour care and monitoring.
 Patient monitoring
equipment includes the
following:

Acute care physiologic monitoring system—
comprehensive patient monitoring systems that can
be configured to continuously measure and display a
number of parameters via electrodes and sensors
that are connected to the patient.

These may include the electrical activity of the heart
via an EKG, respiration rate (breathing), blood
pressure, body temperature, cardiac output, and
amount of oxygen and carbon dioxide in the blood.

Each patient bed in an ICU has a physiologic
monitor that measure these body activities.

All monitors are networked to a central nurses'
station.
 Patient monitoring
equipment includes the
following:
 Pulse oximeter — monitors the arterial
hemoglobin oxygen saturation (oxygen
level) of the patient's blood with a sensor
clipped over the finger or toe.
 Intracranial pressure monitor —
measures the pressure of fluid in the brain in
patients with head trauma or other
conditions affecting the brain (such as
tumors, edema, or hemorrhage). These
devices warn of elevated pressure and record
or display pressure trends. Intracranial
pressure monitoring may be a capability
included in a physiologic monitor.
 Patient monitoring
equipment includes the
following:

Apnea monitor — continuously monitors
breathing via electrodes or sensors placed on
the patient. An apnea monitor detects
cessation of breathing in infants and adults at
risk of respiratory failure, displays respiration
parameters, and triggers an alarm if a certain
amount of time passes without a patient's
breath being detected. Apnea monitoring may
be a capability included in a physiologic
monitor.
 Life support and
emergency resuscitative
equipment

Ventilator (also called a respirator)—assists
with or controls pulmonary ventilation in
patients who cannot breathe on their own.

Ventilators consist of a flexible breathing
circuit, gas supply,
heating/humidification mechanism,
monitors, and alarms.

They are microprocessor-controlled and
programmable, and regulate the volume,
pressure, and flow of patient respiration.
Ventilator monitors and alarms may interface
with a central monitoring system or
information system.
 Life support and
emergency resuscitative
equipment
 Infusion pump — device that delivers fluids
intravenously or epidurally through a catheter. Infusion
pumps employ automatic, programmable pumping
mechanisms to deliver continuous anesthesia, drugs,
and blood infusions to the patient. The pump is hung on
an intravenous pole placed next to the patient's bed.
 Crash cart — also called a resuscitation or code
cart. This is a portable cart containing emergency
resuscitation equipment for patients who are "coding."
That is, their vital signs are in a dangerous range.
 The emergency equipment includes a defibrillator,
airway intubation devices, a resuscitation
bag/mask, and medication box. Crash carts are
strategically located in the ICU for immediate availability
for when a patient experiences cardiorespiratory failure.
 Patient monitoring
equipment includes the
following:

Intraaortic balloon pump — a device that
helps reduce the heart's workload and helps
blood flow to the coronary arteries for
patients with unstable angina, myocardial
infarction (heart attack), or patients
awaiting organ transplants.

Intraaortic balloon pumps use a balloon
placed in the patient's aorta. The balloon is
on the end of a catheter that is connected
to the pump's console, which displays heart
rate, pressure, and electrocardiogram (ECG)
readings. The patient's ECG is used to time
the inflation and deflation of the balloon.
 Diagnostic equipment
 The use of diagnostic equipment is also
required in the ICU.
 Mobile x-ray units are used for bedside
radiography, particularly of the chest.
Mobile x-ray units use a battery-operated
generator that powers an x-ray tube.
 Handheld, portable clinical laboratory
devices, or point-of-care analyzers, are
used for blood analysis at the bedside. A
small amount of whole blood is required,
and blood chemistry parameters can be
provided much faster than if samples were
sent to the central laboratory.
 Other ICU equipment
 Disposable ICU equipment includes urinary
(Foley) catheters, catheters used for arterial
and central venous lines, Swan-Ganz
catheters, chest and endotracheal tubes,
gastrointestinal and nasogastric feeding tubes,
and monitoring electrodes.
 Some patients may be wearing a posey vest,
also called a Houdini jacket for safety; the
purpose is to keep the patient stationary.
Spenco boots are padded support devices
made of lamb's wool to position the feet and
ankles of the patient. Support hose may also
be placed on the patient's legs to support the
leg muscles and aid circulation.
 Maintenance
 Since ICU equipment is used continuously on
critically ill patients, it is essential that equipment
be properly maintained, particularly devices
that are used for life support and
resuscitation.
 Staff in the ICU should perform daily checks
on equipment and inform biomedical engineering
staff when equipment needs maintenance, repair,
or replacement.
 For mechanically complex devices, service and
preventive maintenance contracts are available
from the manufacturer or third-party servicing
companies, and should be kept current at all times.